What are the essential health benefits required in ACA plans?
What types of medical services must be covered by all ACA-compliant health insurance plans?
All ACA-compliant health insurance plans are required to cover a set of essential health benefits (EHBs) to ensure that individuals and families have access to comprehensive healthcare services. These benefits are standardized across all plans in the ACA Marketplace, meaning that no matter which plan you choose—whether it's Bronze, Silver, Gold, or Platinum—the plan must cover certain critical medical services. Here’s an overview of the types of medical services that must be covered by all ACA-compliant health insurance plans:
1. Ambulatory Patient Services
Ambulatory care refers to outpatient services, which are healthcare services you receive without being admitted to a hospital. This includes:
Doctor visits (e.g., primary care, specialists).
Outpatient surgery.
Lab tests.
Same-day procedures.
Ambulatory services allow you to receive medical care and return home the same day.
2. Emergency Services
All ACA plans must cover emergency care without requiring pre-authorization or charging higher out-of-network costs. This ensures that you can get care during an emergency situation, such as:
Emergency room visits.
Ambulance services.
Urgent care services.
Emergency services are covered whether the hospital or provider is in-network or out-of-network.
3. Hospitalization
ACA plans cover inpatient care when you are admitted to the hospital for treatment. This includes services such as:
Surgeries.
Hospital stays.
Post-operative care.
Specialist consultations during hospitalization.
Hospitalization coverage is essential for more serious health conditions that require longer-term treatment.
4. Maternity and Newborn Care
Maternity care and newborn care are covered from the start of pregnancy through delivery and postpartum care. This includes:
Prenatal visits.
Labor and delivery.
Postnatal care for the mother and baby.
Newborn screenings.
Maternity and newborn care must be covered by all ACA plans, ensuring comprehensive care for both mothers and infants.
5. Mental Health and Substance Use Disorder Services
Mental health and behavioral health services are an essential part of ACA coverage. Plans must cover:
Therapy (individual and group counseling).
Substance use disorder treatment (rehabilitation services).
Psychiatric care.
Medication for mental health conditions.
These services must be covered at the same level as physical health services, ensuring parity between mental health and medical benefits.
6. Prescription Drugs
All ACA plans must provide coverage for prescription medications. This includes a wide range of medications for treating chronic conditions, acute illnesses, and mental health conditions.
Formulary: Each plan must include a list of covered drugs (called a formulary) that spans a broad range of drug classes.
Plans must cover at least one drug in each therapeutic category.
Prescription drug coverage ensures that individuals can access the medications they need to manage their health.
7. Rehabilitative and Habilitative Services and Devices
ACA plans cover both rehabilitative services (to help you recover skills lost due to illness or injury) and habilitative services (to help you acquire or improve skills needed for daily life). These services include:
Physical therapy.
Occupational therapy.
Speech therapy.
Medical devices (e.g., wheelchairs, prosthetics).
These services are important for individuals recovering from surgery or illness, as well as those with disabilities.
8. Laboratory Services
Lab tests that are necessary for diagnosis and treatment are covered by all ACA plans. These services include:
Blood tests.
X-rays.
MRIs and CT scans.
Lab services are an essential part of preventive care, diagnostics, and ongoing treatment plans.
9. Preventive and Wellness Services and Chronic Disease Management
All ACA plans must cover a range of preventive services at no cost to you, even if you haven’t met your deductible. This includes services such as:
Annual physicals.
Immunizations (e.g., flu shots, COVID-19 vaccines).
Cancer screenings (e.g., mammograms, colonoscopies).
Blood pressure, cholesterol, and diabetes screenings.
Preventive services are intended to catch potential health issues early and reduce the risk of serious conditions. Additionally, chronic disease management services are covered for those with ongoing health issues like diabetes, asthma, or heart disease.
10. Pediatric Services, Including Oral and Vision Care
For children, ACA plans must cover pediatric care, which includes:
Well-child visits.
Vaccinations.
Vision screenings and glasses.
Dental services such as exams, cleanings, and fillings.
Pediatric oral and vision care is mandatory under ACA-compliant plans, ensuring that children have access to comprehensive care from an early age.
Key Takeaways:
ACA-compliant health plans are required to cover a broad range of essential health benefits (EHBs), including preventive care, mental health services, prescription drugs, hospitalization, and more.
Many preventive services are covered at no cost to you, even before meeting your deductible.
These benefits are included in all plans, whether you choose a Bronze, Silver, Gold, or Platinum tier.
For personalized assistance in selecting a plan that covers your healthcare needs, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
